Association of Body Mass Index With Clinical Outcomes in Patients With Atrial Fibrillation: A Report From the FANTASIIA Registry

Abstract

Background Obesity and atrial fibrillation (AF) frequently coexist and independently increase mortality. We sought to assess the association between obesity and adverse events in patients receiving oral anticoagulants for AF. Methods and Results Consecutive AF outpatients receiving anticoagulant agents (both vitamin K antagonists and direct oral anticoagulants) were recruited into the FANTASIIA (Atrial fibrillation: influence of the level and type of anticoagulation on the incidence of ischemic and hemorrhagic stroke) registry. This observational, multicenter, and prospective registry of AF patients analyzes the quality of anticoagulation, incidence of events, and differences between oral anticoagulant therapies. We analyzed baseline patient characteristics according to body mass index, normal: <25 kg/m², overweight: 25-30 kg/m², and obese: ≥30 kg/m²), assessing all-cause mortality, stroke, major bleeding and major adverse cardiovascular events (a composite of ischemic stroke, myocardial infarction, and total mortality) at 3 years' follow-up. In this secondary prespecified substudy, the association of weight on prognosis was evaluated. We recruited 1956 patients (56% men, mean age 73.8±9.4 years): 358 (18.3%) had normal body mass index, 871 (44.5%) were overweight, and 727 (37.2%) were obese. Obese patients were younger (P<0.01) and had more comorbidities. Mean time in the therapeutic range was similar across body mass index categories (P=0.42). After a median follow-up of 1070 days, 255 patients died (13%), 45 had a stroke (2.3%), 146 a major bleeding episode (7.5%) and 168 a major adverse cardiovascular event (8.6%). Event rates were similar between groups for total mortality (P=0.29), stroke (P=0.90), major bleeding (P=0.31), and major adverse cardiovascular events (P=0.24). On multivariate Cox analysis, body mass index was not independently associated with all-cause mortality, cardiovascular mortality, stroke, major bleeding, or major adverse cardiovascular events. Conclusions In this prospective cohort of patients anticoagulated for AF, obesity was highly prevalent and was associated with more comorbidities, but not with poor prognosis.

Keywords: atrial fibrillation; mortality; obesity; prognosis; risk factors.

Figure 1

Kaplan–Meier survival estimates. A, Mortality, (B) stroke, (C) major bleeding, and (D) MACE (composite of ischemic stroke, myocardial infarction, and cardiovascular and total mortality). MACE indicates major adverse cardiovascular events.

Figure 2

Association between BMI and the estimated 3‐year survival probability including BMI as a continuous variable using restricted cubic splines with 3 degrees of freedom. The dotted lines represent the 95% CI. (A) Mortality, (B) stroke, (C) major bleeding, and (D) MACE (composite of ischemic stroke, myocardial infarction, and cardiovascular and total mortality). The models were adjusted by age, sex, hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, heart failure, aortic artery disease, chronic kidney disease, Charlson index, previous stroke, CHA ₂ DS ₂‐VASc, and HAS‐BLED. BMI indicates body mass index; MACE, major adverse cardiovascular events.

Figure 3

Association between BMI and the estimated 3‐year survival probability including BMI as a continuous variable using restricted cubic splines with 3 degrees of freedom. The dotted lines represent the 95% CI. A, Mortality, (B) stroke, (C) major bleeding, and (D) MACE (composite of ischemic stroke, myocardial infarction, and cardiovascular and total mortality). The models were adjusted by age. BMI indicates body mass index; MACE, major adverse cardiovascular events.